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Please prsnt or type. <br /> 1.Generator ID Number Form Approved.OfNl3 No.2050-0039 <br /> UNIFORM HAZARDOUS 2,Page 1 of 3.Emergency Response Phone 4.Manfest Tracking Number <br /> WASTE MANfFEST ��$ $ $Dt -42$-�$Qa 0 2 0 7 9 0 6 8 JJ!( <br /> 3.G ner tops Name aili Address Generators Site Address(if dit3erenl Ihan mailing addressl <br /> 3927 8i &la ik ktsn <br /> 3927 Cl&Wk Daeivo 3927 Clark DrAve Atte' Frank Wilkerson <br /> st*cktOU, CA 95205 Stockton, CA 9.3203 <br /> Generators Phone: 916 240-3365 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> WoViAwida R+ lipy fltt s -TUC <br /> 7.Transporter 2 Company Name CAR00017 3312 <br /> U.S.EPA ID Number- <br /> 8JWedjW,.Uy{NaW Site Address U.S.EPA ID Number <br /> 2730 E. 13TH 6TRZET <br /> Fadlitys Phone: 02$-343-0820 <br /> 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1g.Containers <br /> HM and Packing Group(If any)) 11.Total 12.Unit 13.Waste Codes <br /> Nc. Type Quantity WL/Val. <br /> 1. 110n—RCRA llaxardoiag WaXtg Ootid (japty iFoly <br /> 312 <br /> a3oo F <br /> 2. <br /> LU <br /> 3. <br /> 4. <br /> 14&S# HI1�s1NcRRIS tions and Additional Information <br /> Hill to VW,,- Wear J?ro 'VPE clathLAg1 **In cams of ' <br /> 424-9200 BAgiatrant *CCS 97473 •411 -1 ALO K � �Qsr ���Y coatact <br /> V0#544523 �aRXC (800) <br /> n <br /> 15, GENERATOR's10FFEROR'S CERTIFICATION: I hereby d clan that the contents of this consignment are fully and accurately described above by the proper shipping name,aril are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper conditon(or transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement idengfred in 40 CFR 262.27(a)(if I ars a large quantity generator)or(b)(dl am a small yped Na quantity generator)is true. <br /> tedlT <br /> v <br /> Month Day Year <br /> 1 16.International Shipments <br /> Transporter signature(for exports only Impart to U.S. ❑Export from U.S, flrt of entryiexit: <br /> W 17.Transporter Aeknowledgmarri of Receipt of Materials Date leaving U.S.: <br /> Transpo err 1 , ped Name <br /> Signature <br /> Month Day Year <br /> Z Transporter 2 PnntedlTyped ame 4 <br /> Signature <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ r�i'''�� <br /> Quantity ❑Type E l Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Altemate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> w t6c.SignatureOf Alternate Facility(or Generator) <br /> Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(Le,,codas for hazardous waste treatment,disposal,and recycling systems) <br /> LLA 1• 2, 3. <br /> 4. <br /> 20.Dpaignated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 16a <br /> Printed/Typed Name Signature <br /> Month Day Year <br /> EPA Farm 8700.22(Rev,12-17) Previous editions are obsolete. DESIGaNATED FACILITY TQ EPA's e-MANIFEST SYSTEM <br />